Healthcare Provider Details

I. General information

NPI: 1477497147
Provider Name (Legal Business Name): CARLOS JUAREZ CCSS,CSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2026
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3402 BOX CANYON AVE
GALLUP NM
87301-6903
US

IV. Provider business mailing address

3402 BOX CANYON AVE
GALLUP NM
87301-6903
US

V. Phone/Fax

Practice location:
  • Phone: 505-879-2954
  • Fax:
Mailing address:
  • Phone: 505-879-2954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: